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Pre-consultation

When you book an appointment, we will send you a pre-consultation form. We want to make sure everyone can complete this with ease. If you would like the form in a language other than English or in a format that better suits your needs, please email us at info@beautifullifestyle.co.uk, and we will do our best to help.

 

We want everyone to be able to access our services easily. If you find it difficult to use the internet, need help with technology, or have a disability that makes accessing online services challenging—such as vision, hearing, or mobility difficulties—please let us know. We can connect you with free support to help with using digital devices, getting online, or accessing information in a way that works best for you.

Pre-consultation form

Pre-Consultation Form

​Thank you for choosing to seek my advice. I admire your initiative to make things happen in your life. I encourage the decision you have made. I now need to make sure I can help you before embarking on a journey together. I am committed to helping in the best way I can, which is why I have to carefully decide if I am the right person for you, or if I could recommend colleagues with other kinds of expertise.

Would you please complete this form with as much information as possible, so that I would have a clear understanding of what you need, your mind set, to understand what is and isn’t working yet and envision your initial goals. The form covers different aspects, as lifestyle medicine has a coaching part and a medical knowledge part.

Please take your time when completing it. Give yourself space to put all the important and relevant things. Answer each question openly. If there is sensitive information, which you would like to discuss rather than write down, please make a note of that. Your answers will be kept confidential and will never be shared with anyone, unless I consider there would be a danger to yourself or another person. I (Lulia Danciut) am the only one who will see this.

Date of Birth
Day
Month
Year
Multi-line address
Dropdown

Lifestyle

(includes previous surgeries, reasons for hospital or GP attendance)

(involving parents, grandparents, children, siblings, aunts/uncles)

Including vitamins and naturistic treatments

Dietary Habits

(per day/week)

(e.g., vegetarian, Mediterranean, keto)

Physical Activity

(e.g. daily, 3x/week)

(e.g., walking, running, yoga, strength training)

Sleep Patterns

Do you have trouble falling or staying asleep?
Yes
No
Do you wake up feeling rested?
Yes
No

Stress Levels

On a scale from 1 (low) to 10 (high)

(e.g., work, family, health)

(e.g. meditation, exercise)

Do you have a strong social support system?
Yes
No

(family, friends)

Do you feel safe and supported in your home and community?
Yes
No

(e.g., work, neighborhood)

Strengths & Areas of development

If so, what?

What are your reasons? Be specific.

On a scale of 1-10, with 1 being not at all, and 10 being entirely.

How committed are you to achieving and completing your stated goals?

On a scale of 1-10, with 1 being not at all, and 10 being entirely.

Thank you for taking the time to complete this form. Click to Submit.

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